Q&A: Outpatient documentation for failed response to ulcer treatment

Q: I was recently informed that providers use cellular-based tissue products (CTP) to treat ulcers when a patient fails to respond to more conservative treatment options. What constitutes a failed response to treatment and how would this be documented?

A: To meet medical necessity requirements under Medicare, prior to using CTP to treat an ulcer, a provider must first report a failed response to more conservative treatments options such as debridement, moist dressings, or off-loading.

Provider documentation of a response to ulcer treatment should include measurements of the ulcer at baseline and following cessation of conservative or conventional management. A failed response may be documented as:

• An ulcer that increased in size or depth after treatment.
• An ulcer that did not change in baseline size or depth and has shown no signs of improvement or indications that improvement is likely. The ulcer may have granulated, epithelialized, or progressed toward closing.

In these situations, it’s clear that the wound is not responding to treatment.

Insurance carriers typically instruct providers to employ the least costly option for ulcer treatment before moving on to more expensive options. You can compare this to getting an X-ray before magnetic resonance imaging (MRI). Patients typically get an X-ray before an MRI, even though it is less detailed than an MRI, because X-rays are less expensive for a facility to perform.

Editor’s note: Gloria Miller, CPC, CPMA, CPPM, vice president of reimbursement services at Comprehensive Healthcare Solutions Inc. in Seattle, answered this question during the HCPro webinar, “Combat Outpatient Wound Care Coding and Documentation Challenges in 2019.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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